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Akhtar Z, Sohal M, Sheppard MN, Gallagher MM. Transvenous Lead Extraction: Work in Progress. Eur Cardiol 2023; 18:e44. [PMID: 37456768 PMCID: PMC10345938 DOI: 10.15420/ecr.2023.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/10/2023] [Indexed: 07/18/2023] Open
Abstract
Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
| | - Manav Sohal
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
| | - Mary N Sheppard
- Cardiac Risk in the Young, Cardiovascular Pathology Unit, St George's University of LondonLondon, UK
| | - Mark M Gallagher
- Department of Cardiology, St George's University Hospital NHS Foundation TrustLondon, UK
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2
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A Novel Video-Assisted Approach to Excimer Laser-Guided Cardiac Implantable Electronic Devices Lead Extraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:210-3. [PMID: 27537189 DOI: 10.1097/imi.0000000000000277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Even though roughly 90% of all implanted cardiac implantable electronic devices leads can be removed through conventional techniques, presence of large vegetations or thrombi, fractured leads, previous failed extraction, or long duration from implantation often impede classical transvenous extraction. In these cases, laser-assisted procedures represent a highly successful alternative and have a low procedural complication rate with major adverse events in less than 2% of cases. Unfortunately, most encountered complications are potentially fatal, which prompted us to develop a novel approach that adds additional safety measures by allowing for real-time intrathoracic visualization and intervention. METHODS Five consecutive patients classified as high-risk patients received concomitant laser sheet extraction and right-sided uniportal video-assisted thoracic surgery for real-time intrathoracic visualization. RESULTS Complete extraction was achieved in all cases without observing major intraoperative events, and on-table extubation was feasible in all cases. No chest tube-associated or incision-related complications were encountered. CONCLUSIONS Concomitant laser sheet extraction and video-assisted thoracoscopy are feasible and may offer benefits in high-risk patients. Further studies to document the actual safety and clinical value of our procedure are warranted.
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Zardo P, Busk H, Hadem J, Baraki H, Kensah G, Kutschka I. A Novel Video-Assisted Approach to Excimer Laser-Guided Cardiac Implantable Electronic Devices Lead Extraction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Patrick Zardo
- Division of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Henning Busk
- Division of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Johannes Hadem
- Division of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Hassina Baraki
- Division of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - George Kensah
- Division of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Ingo Kutschka
- Division of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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GOYAL SANDEEPK, ELLIS CHRISTOPHERR, BALL STEPHENK, AHMAD RASHID, HOFF STEVENJ, WHALEN SPATRICK, ROTTMAN JEFFREY. High-Risk Lead Removal by Planned Sequential Transvenous Laser Extraction and Minimally Invasive Right Thoracotomy. J Cardiovasc Electrophysiol 2014; 25:617-21. [DOI: 10.1111/jce.12368] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/10/2013] [Accepted: 12/26/2013] [Indexed: 11/27/2022]
Affiliation(s)
- SANDEEP K. GOYAL
- Vanderbilt Heart and Vascular Institute; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - CHRISTOPHER R. ELLIS
- Vanderbilt Heart and Vascular Institute; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - STEPHEN K. BALL
- Vanderbilt Heart and Vascular Institute; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - RASHID AHMAD
- Vanderbilt Heart and Vascular Institute; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - STEVEN J. HOFF
- Vanderbilt Heart and Vascular Institute; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - S. PATRICK WHALEN
- Vanderbilt Heart and Vascular Institute; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - JEFFREY ROTTMAN
- Department of Veteran Affairs; Tennessee Valley Healthcare System; Nashville Tennessee USA
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Amraoui S, Barandon L, Whinnett Z, Ploux S, Labrousse L, Denis A, Oses P, Ritter P, Haissaguerre M, Bordachar P. Single surgical procedure combining epicardial pacemaker implantation and subsequent extraction of the infected pacing system for pacemaker-dependent patients. J Thorac Cardiovasc Surg 2012; 146:302-5. [PMID: 22964353 DOI: 10.1016/j.jtcvs.2012.07.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 07/09/2012] [Accepted: 07/23/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Management of pacemaker infection in pacing-dependent patients is often challenging. Typically, temporary pacing is used while antibiotic therapy is given for a number of days before reimplantation of a new endocardial system. This results in a prolonged hospital stay and complications associated with temporary pacing. In this study, we examine the feasibility of performing a single combined procedure of epicardial pacemaker implantation followed by system extraction. METHODS One hundred consecutive infected pacemaker-dependent patients underwent implantation of 2 epicardial ventricular leads and were converted to a ventricular demand pacing system. The infected pacing system was then extracted during the same procedure. Patients were followed up for 12 months. RESULTS Significant pericardial bleeding developed during the procedure in 3 patients. The presence of the pericardial drain positioned during the implantation of the epicardial pacing system meant that cardiac tamponade did not occur, allowing surgical repair with sternotomy to be carried out under stable hemodynamic conditions. Two of these 100 patients died in the 30-day postoperative period; 1 death was due to septic shock and 1 to pulmonary distress. Median 1-year epicardial pacing thresholds were stable and excellent (1.4 ± 0.9 volts). However, 1 of the 2 leads developed increased thresholds in 6 patients, which led to the exclusive use of other ventricular lead. CONCLUSIONS A single combined procedure of surgical epicardial pacemaker implantation and pacemaker system extraction appears to be a safe and effective method for managing pacemaker-dependent patients with infected pacemakers.
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Affiliation(s)
- Sana Amraoui
- Bordeaux University 2 and University Medical Center of Bordeaux, Bordeaux, France
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Percutaneous pacemaker and implantable cardioverter-defibrillator lead extraction in 100 patients with intracardiac vegetations defined by transesophageal echocardiogram. J Am Coll Cardiol 2010; 55:886-94. [PMID: 20185039 DOI: 10.1016/j.jacc.2009.11.034] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Revised: 10/07/2009] [Accepted: 11/02/2009] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We describe the feasibility, safety, and clinical outcomes of percutaneous lead extraction in patients at a tertiary care center who had intracardiac vegetations identified by transesophageal echocardiogram. BACKGROUND Infection in the presence of intracardiac devices is a problem of considerable morbidity and mortality. Patients with intracardiac vegetations are at high risk for complications related to extraction and protracted clinical courses. Historically, lead extraction in this cohort has been managed by surgical thoracotomy. METHODS We analyzed percutaneous lead extractions performed from January 1991 to September 2007 in infected patients with echocardiographic evidence of intracardiac vegetations, followed by a descriptive and statistical analysis. RESULTS A total of 984 patients underwent extraction of 1,838 leads; local or systemic infection occurred in 480 patients. One hundred patients had intracardiac vegetations identified by transesophageal echocardiogram, and all underwent percutaneous lead extraction (215 leads). Mean age was 67 years. Median extraction time was 3 min per lead; median implant duration was 34 months. During the index hospitalization, a new device was implanted in 54 patients at a median of 7 days after extraction. Post-operative 30-day mortality was 10%; no deaths were related directly to the extraction procedure. CONCLUSIONS Patients with intracardiac vegetations identified on transesophageal echocardiogram can safely undergo complete device extraction using standard percutaneous lead extraction techniques. Permanent devices can safely be reimplanted provided blood cultures remain sterile. The presence of intracardiac vegetations identifies a subset of patients at increased risk for complications and early mortality from systemic infection despite device extraction and appropriate antimicrobial therapy.
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8
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Rusanov A, Spotnitz HM. A 15-Year Experience With Permanent Pacemaker and Defibrillator Lead and Patch Extractions. Ann Thorac Surg 2010; 89:44-50. [DOI: 10.1016/j.athoracsur.2009.10.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Revised: 10/08/2009] [Accepted: 10/12/2009] [Indexed: 11/25/2022]
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Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH, Epstein LM, Friedman RA, Kennergren CEH, Mitkowski P, Schaerf RHM, Wazni OM. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009; 6:1085-104. [PMID: 19560098 DOI: 10.1016/j.hrthm.2009.05.020] [Citation(s) in RCA: 768] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Indexed: 12/20/2022]
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10
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SMITH MACYC, LOVE CHARLESJ. Extraction of Transvenous Pacing and ICD Leads. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:736-52. [DOI: 10.1111/j.1540-8159.2008.01079.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kennergren C, Bucknall CA, Butter C, Charles R, Fuhrer J, Grosfeld M, Tavernier R, Morgado TB, Mortensen P, Paul V, Richter P, Schwartz T, Wellens F. Laser-assisted lead extraction: the European experience. ACTA ACUST UNITED AC 2007; 9:651-6. [PMID: 17597078 DOI: 10.1093/europace/eum098] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS The aim of this study is to investigate the safety and effectiveness of Excimer laser-assisted lead extraction in Europe. The final European multi-centre study experience is presented. METHOD AND RESULTS The Excimer is a cool cutting laser (50 degrees C) with a wavelength of 308 nm. The energy is emitted from the tip of a flexible sheath and is absorbed by proteins and lipids, 64% of the energy is absorbed at a tissue depth of 0.06 mm. The sheath is positioned over the lead, and the fibrosis surrounding the lead is vaporized while advancing the sheath without damaging other leads. From August 1996 to March 2001, 383 leads (170 atrial, 213 ventricular) in 292 patients (mean age 61.6 years, range 13-96) were extracted at 14 European centres. Mean implantation time was 74 months (3-358). Most frequent indications were pocket infection (26%), non-functional leads (21%), patient morbidity (21%), septicaemia or endocarditis (14%), erosion (5%), and lead interference (8%). Median extraction time was 15 min (1-300). Complete extraction was achieved in 90.9% of the leads and partial extraction in 3.4%. Extraction failed in 5.7% of the leads. Major complications = perforations caused 10/22 (3.4/5.7%) of the failures. Most partially extracted patients were considered clinically successful, as only minor lead parts without clinical significance were left. Femoral non-laser technique was used to remove 8/12 of the non-complication failures. The total complication rate, including five minor complications (1.7%), was 5.1%. No in-hospital mortality occurred. CONCLUSION Pacing and implantable cardioverter-defibrillator leads can safely, effectively, and predictably be extracted. Open-heart extractions can be limited to special cases. The results indicate that the traditional policy of abandoning redundant leads, instead of removing them, may be obsolete in many patients.
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Affiliation(s)
- C Kennergren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden.
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12
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Khitin L, Kim K, Kratz J. Transxyphoid Approach to Retrieval of Retained Pacemaker Leads Using Laser Sheath. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:157-9. [PMID: 15679647 DOI: 10.1111/j.1540-8159.2005.09361.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The problem of retained intracardiac foreign bodies remains a concern, particularly in symptomatic patients with endocarditis. This report describes a recently applied technique using transxyphoid application of the Spectranetics Laser Sheath (SLS) for retrieval of a retained right atrial (RA) pacemaker lead. This approach represents modification of the Byrd's technique.
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Affiliation(s)
- Lev Khitin
- Department of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Yuasa S, Masuyama S, Soeda T, Matsuda M, Shirota K, Taira H. Surgical removal of an accufix pacing lead with a protruding J wire. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2002; 50:443-4. [PMID: 12428386 DOI: 10.1007/bf02913180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a patient with a fractured J wire protruding through the outer polyurethane sheath of an Accufix electrode in the subclavian vein and right atrium. The wire within the subclavian vein was removed transvenously, while the tip of the lead within the right atrium was removed surgically via a median sternotomy.
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Affiliation(s)
- Sadatosh Yuasa
- Department of Cardiovascular Surgery, Matsue Red Cross Hospital, 200 Horomachi, Matsue 690-8506, Japan
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Treatment strategy for infections in patients with permanent pacemakers. J Artif Organs 2001. [DOI: 10.1007/bf02479893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
The removal of chronically implanted pacemaker and defibrillator leads has evolved over the past 20 years into an integral part of the medical and surgical practice of electrophysiology. It is the basis for management of device-related complications. Lead removal has progressed from just pulling, to a sophisticated procedure based on telescoping sheaths, counterpressure, and countertraction. Current telescoping sheaths have a powered tip (laser or electrosurgical) for more efficient extirpation of leads from encapsulating fibrous tissue. The management of a device infection exemplifies the spectrum of procedures ranging from debridement of inflammatory tissue to transvenous, transatrial, or epicardial lead reimplantation (care must be given to the consequences of chronic implant complications such as superior vein occlusion). The magnitude of these lead removal procedures ranges from a transvenous procedure to cardiopulmonary bypass removing a pannus of infected material. Current procedure related mortality is less than 0.2% at experienced centers.
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Affiliation(s)
- C L Byrd
- 1625 Southeast Third Avenue, Suite 610, Fort Lauderdale, FL 33316, USA
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Love CJ, Wilkoff BL, Byrd CL, Belott PH, Brinker JA, Fearnot NE, Friedman RA, Furman S, Goode LB, Hayes DL, Kawanishi DT, Parsonnet V, Reiser C, Van Zandt HJ. Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty. Pacing Clin Electrophysiol 2000; 23:544-51. [PMID: 10793452 DOI: 10.1111/j.1540-8159.2000.tb00845.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In addition, since at this time the only prospective scientific study of lead extraction is the PLEXES trial, we suggest that studies relating to the techniques of and indications for lead extraction be designed. Recommendations for a common set of definitions, for a framework of training and reviewing physicians in the art, for general methods of reimbursement, and for consistency among clinical trials have been made. Implementation of these recommendations will require additional effort and cooperation from practicing physicians, medical societies, hospital administrations, and industry.
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Abstract
Extraction of chronically implanted pacing leads involves a thorough understanding of the pathophysiology of lead maturation and the problems that may occur. It also requires specific knowledge of lead construction and the idiosyncrasies of individual lead models. Though we have evolved to use a standardized approach to lead extraction, each patient and lead removal is unique. The operator must be ready to adapt the technique and tools used to the situation at hand. The more experience and the more tools available to the operator, the more likely that there will be a safe and successful outcome to the procedure. Preparation for disaster is mandatory, such that when a complication does occur, one may respond quickly and therefore salvage the patient.
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Affiliation(s)
- C J Love
- Arrhythmia Device Services, Ohio State University, Columbus, USA.
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Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Turk KT, Reeves R, Young R, Crevey B, Kutalek SP, Freedman R, Friedman R, Trantham J, Watts M, Schutzman J, Oren J, Wilson J, Gold F, Fearnot NE, Van Zandt HJ. Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute. Pacing Clin Electrophysiol 1999; 22:1348-57. [PMID: 10527016 DOI: 10.1111/j.1540-8159.1999.tb00628.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Of the 400,000-500,000 permanent pacemaker leads implanted worldwide each year, around 10% may eventually fail or become infected, becoming potential candidates for removal. Intravascular techniques for removing problematic or infected leads evolved over a 5-year period (1989-1993). This article analyzes results from January 1994 through April 1996, a period during which techniques were fairly stable. Extraction of 3,540 leads from 2,338 patients was attempted at 226 centers. Indications were: infection (27%), nonfunctional or incompatible leads (25%), Accufix or Encore leads (46%), or other causes (2%). Patients were 64+/-17 years of age (range 5-96); 59% were men, 41% women. Leads were implanted 47+/-41 months (maximum 26 years), in the atrium (53%), ventricle (46%), or SVC (1%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths, and/or transfemorally using snares, retrieval baskets, and sheaths. Complete removal was achieved for 93% of leads, partial for 5%, and 2% were not removed. Risk of incomplete or failed extraction increased with implant duration (P<0.0001), less experienced physicians (P<0.0001), ventricular leads (P<0.005), noninfected patients (P<0.0005), and younger patients (P<0.0001). Major complications were reported for 1.4% of patients (<1% at centers with >300 cases), minor for 1.7%. Risk of complications increased with number of leads removed (P<0.005) and with less experienced physicians (P<0.005); risk of major complications was higher for women (P<0.01). Given physician experience, appropriate precautions, and appropriate patient selection, contemporary lead removal techniques allow success with low complication rates.
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Affiliation(s)
- C L Byrd
- University of Miami School of Medicine, Florida, USA
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Kennergren C. Excimer laser assisted extraction of permanent pacemaker and ICD leads: present experiences of a European multi-centre study. Eur J Cardiothorac Surg 1999; 15:856-60. [PMID: 10431870 DOI: 10.1016/s1010-7940(99)00123-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Excimer Laser technique can be used to extract leads. We present the European multi-centre experience. METHOD The Spectranetics Excimer Laser is a Xenon-Chloride laser with a wavelength of 308 nm, not visible to the human eye. This cool cutting laser (50 degrees C) has an absorption depth of 0.06 mm. The laser energy is emitted from the tip of flexible 12, 14 or 16 French (Fr) probes and is absorbed by proteins and lipids. The fibrotic sheaths usually surrounding leads can be cut without damaging the endothelial wall or the insulation of other leads. RESULTS From August 1996 to August 1998, 179 leads (104 atrial, 57 ventricular, one SVC, 17 ICD) in 149 patients (mean age 68.3 years, range 14-94) were extracted in 11 centres. Mean implantation time was 68.3 months (2.8-357.8). Most common indications were patient morbidity, non-function, pocket infection, septicaemia or endocarditis. Median extraction time was 10 min (1-189). Most procedures (78%) were performed in operating rooms. Complete extraction was achieved in 89.5% of the leads, 6% were partially extracted and 4.5% of the extractions failed. In the majority of the partial cases, only minor lead parts without clinical significance were left. Of the failures, 3/8 were completely removed by femoral non-laser approach, 1/8 with a right subclavian approach and 1/8 with thoracotomy. Complications were few but included one ventricular perforation that did not need surgery; two other perforations were related to the reimplantation of leads and required surgery. Mean hospital stay was 3 days and all patients were discharged well and alive. CONCLUSIONS Excimer Laser assisted lead extraction is a safe and efficacious procedure. Open-chest extractions are still necessary but can be limited to very selected cases. These initial results may widen indications from mandatory to include the extraction of many non-functional leads, previously abandoned.
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Affiliation(s)
- C Kennergren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden.
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Goldstein DJ, Rabkin D, Spotnitz HM. Unconventional approaches to cardiac pacing in patients with inaccessible cardiac chambers. Ann Thorac Surg 1999; 67:952-8. [PMID: 10320234 DOI: 10.1016/s0003-4975(99)00150-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transvenous endocardial implantation can be impossible or contraindicated in patients with inaccessible right cardiac chambers. These patients usually undergo epicardial implantation, which has been associated with frequent rising thresholds and limited lead survival. We have used the following two alternative approaches in these patients: (1) transatrial puncture and passage of pacing leads for patients with no access to the right atrium and (2) ventricular pacing from the coronary sinus or its tributaries for patients with inaccessible ventricles. METHODS. We retrospectively reviewed our experience in 9 patients who had those procedures. Five patients had pacing from the coronary sinus, and 4 by transatrial puncture. RESULTS Seven of the 9 patients had DDD pacing. Low acute pacing thresholds and satisfactory sensing levels were obtained with both approaches. One instance of high stimulation threshold (20%) occurred in the coronary sinus group and none in the transatrial puncture group. One patient in the transatrial puncture group died from unrelated causes. No malignant arrhythmias, pneumothorax, diaphragmatic pacing, or infectious complications have been observed. CONCLUSION These unconventional approaches are safe, relatively simple, and reliable. Although the short-term follow-up is favorable, long-term follow-up is necessary to ascertain the relative merit of these approaches.
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Affiliation(s)
- D J Goldstein
- Department of Surgery, College of Physicians & Surgeons, Columbia University, New York, New York 10032, USA.
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21
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Hasegawa S, Morimoto T, Matsuyama N, Okamoto J, Sawada Y, Kondo K, Asada K, Sasaki S. [Removal of the endocardial pacemaker leads--experience with 16 leads in 10 patients]. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 1998; 46:421-7. [PMID: 9654921 DOI: 10.1007/bf03217765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Recent advances in pacemaker leads have contributed to the improvement of their stability at the anchored sites. However, we sometimes have difficulty in removing them. We have experienced the removal of 16 leads in 10 patients (male: 7, female: 3) in the last 5 years. The age of patients ranged from 48 to 87 years, and the average was 60. The reasons for the removal were as follows; pocket infection in 6 cases, sepsis in 1 case, ischemic skin erosion in 1 case, retained fractured ventricular lead in 1 case, fracture of Accufix atrial lead in 1 case. The methods of removal consisted of using the removal kit, the snare or the basket snare transvenously, direct surgical approach or a combination of them. We used the removal kit alone in 12 electrodes (6 atrial, 6 ventricular), and removal of 5 atrial and 3 ventricular leads were successfully by this method only. The removal of 4 leads by kits alone failed, so that 2 ventricular leads were removed transvenously, one atrial and one ventricular lead were removed surgically, and 1 ventricular lead was left untreated. Finally, we were able to remove 15 of 16 leads (93.3%) successfully. This experience indicates that these interventions should be performed as less invasively as possible, yet we should give an explanation to the patients as to the options we may employ when we have failed in the intended procedure.
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Affiliation(s)
- S Hasegawa
- Department of Cardiovascular Surgery, Osaka Medical College, Japan
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Caudill CC, Clinch B, Krueger SK, Gard JR, Turk KT, Wilson CS. Percutaneous extraction of a fractured, exposed atrial "J" lead retention wire. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 37:342-6. [PMID: 8974822 DOI: 10.1002/(sici)1097-0304(199603)37:3<342::aid-ccd29>3.0.co;2-i] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The recent identification of fracturing of the retention wire in the Telectronics atrial lead, models 329-701 and 330-801, and the report of death due to cardiac tamponade caused by aortic puncture resulting from protrusion of the retention wire, necessitates fluoroscopic screening of these patients and the explantation of all leads identified to have the component failure. We present in this paper a percutaneous alternative to lead explantation in patients with protrusion of the retention wire through the polyurethane insulation and with an otherwise properly functioning atrial lead.
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Affiliation(s)
- C C Caudill
- Department of Cardiology, Bryan Memorial Hospital, Lincoln, Nebraska 68506, USA
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Hager WD, Brown L, Ramsby G. Percutaneous removal of infected permanent pacemaker leads using a simple coaxial dilating system. Pacing Clin Electrophysiol 1994; 17:2345-8. [PMID: 7885944 DOI: 10.1111/j.1540-8159.1994.tb02385.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A simple traction-countertraction technique using common and readily available materials was successfully used to remove infected pacemaker leads from two patients. The specific methodology is presented. Although somewhat technically demanding, this approach appears safe and cost-effective. This method provides another way to remove pacemaker leads without resorting to thoracotomy.
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Affiliation(s)
- W D Hager
- Cardiology Division, University of Connecticut Health Center, Farmington 06030
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Niederhäuser U, von Segesser LK, Carrel TP, Laske A, Bauer E, Schönbeck M, Turina M. Infected endocardial pacemaker electrodes: successful open intracardiac removal. Pacing Clin Electrophysiol 1993; 16:303-8. [PMID: 7680459 DOI: 10.1111/j.1540-8159.1993.tb01581.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED The long-term results after open intracardiac removal of infected pacing electrodes are presented. METHODS Between 1985 and 1990 open intracardiac removal of 19 infected pacing electrodes was performed in seven patients (six male and one female), with a mean age of 56 years. The indications were: persisting bacteremia in three; generator pocket infection in four; endocarditis in one; and ventricular tachycardia caused by retracted electrodes in one. All electrodes were fixed in the right heart and extraction by closed methods failed. Percutaneous catheter techniques were not applied in these seven patients. In five patients two ventricular electrodes had to be removed, and in two patients a single one. A total of seven atrial electrodes were removed in six patients (one electrode each in five patients; two electrodes in one patient). All atrial and two ventricular electrodes could be removed through a pursestring suture without use of a pump oxygenator. For the removal of ten ventricular electrodes in six patients (two electrodes each in four patients; 1 electrode each in two patients) a right-sided atriotomy was necessary with cardiopulmonary bypass (CPB). Simultaneously, five new pacing systems were implanted. RESULTS There were no early or late mortalities. In January 1991, all seven patients are alive and in a mean New York Heart Association Class 1,3 of heart failure after a mean interval of 33 months. In all cases the infection could controlled with a simultaneous antimicrobial chemotherapy and the postoperative period was free of major complications. CONCLUSION Open intracardiac removal of retained pacing electrodes with or without use of CPB is a safe procedure without major complications. It is mandatory for all infected pacing electrodes that cannot be extracted by closed methods.
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Affiliation(s)
- U Niederhäuser
- Clinic for Cardiovascular Surgery, University Hospital, Zürich, Switzerland
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Byrd CL, Schwartz SJ, Hedin N, Beach M. Intravascular techniques for extraction of permanent pacemaker leads. J Thorac Cardiovasc Surg 1991. [DOI: 10.1016/s0022-5223(19)36615-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Myers MR, Parsonnet V, Bernstein AD. Extraction of implanted transvenous pacing leads: a review of a persistent clinical problem. Am Heart J 1991; 121:881-8. [PMID: 2000756 DOI: 10.1016/0002-8703(91)90203-t] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Within a few months of implantation, permanent pacemaker leads become ensheathed in fibrocollagenous tissue. This tissue may anchor the lead so that it is difficult, dangerous, or impossible to remove it. Leads with bulbous or finned tips are particularly resistant to extraction. The risks of applying traction to an entrapped lead include induction of bradycardia or ventricular tachycardia and fibrillation, invagination of the right ventricle, avulsion of the right ventricular myocardium or tricuspid valve, hemopericardium, and cardiac tamponade. Forceful traction may result in uncoiling of the conductor, disruption of the insulation, or complete fracture, leaving an intravascular remnant that may embolize or be a source for thrombosis. Although fixation and abandonment of an inactive chronically implanted lead is frequently appropriate and is known to pose little long-term risk, the retained inactive lead may interact adversely with a new active lead and then increase the risk of venous thrombosis, serve as a potential nidus for infection, or produce spurious electrical sensing signals that may be sensed by the pulse generator. Absolute indications for lead removal are those in which there would be a life-threatening situation if the lead were to remain in situ. In the absence of an absolute indication, the decision to proceed with extraction must be made by weighing the potential for serious morbidity or mortality against risks of the extraction technique. Techniques for lead removal include traction and open cardiotomy operations. When a portion of the lead is intravascular, forceps, snares, baskets, countertraction, or lead-transection devices may be used to retrieve the fragment.
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Affiliation(s)
- M R Myers
- Division of Cardiac Electrophysiology, Huntington Hospital, Pasadena, CA 91105
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Byrd CL, Schwartz SJ. Transatrial implantation of transvenous pacing leads as an alternative to implantation of epicardial leads. Pacing Clin Electrophysiol 1990; 13:1856-9. [PMID: 1704554 DOI: 10.1111/j.1540-8159.1990.tb06903.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
State-of-the-art pacing modalities are not readily utilized with conventional epicardial pacing lead implantation techniques. A transatrial implantation technique was developed combining a limited surgical approach with transvenous leads. Six patients who were poor candidates for transvenous implants have received DDD or DDDR pacemakers by this approach. The limited surgical approach includes resection of the third or fourth costal cartilage through a small skin incision, reflection of the pleura, and opening of the pericardium. The introducer and transvenous leads are inserted through a right atrial pursestring suture. The leads are positioned in the right ventricle and right atrium using standard fluoroscopic techniques. Through the incision, the subcutaneous tissue pocket is constructed on the right anterior chest wall. The leads are connected to the pacemaker without the need for adaptors or tunneling. There were no procedure-related complications. The magnitude of the surgery and postoperative morbidity are significantly less than for a standard thoracotomy, median sternotomy, and transdiaphragmatic epigastric or subcostal approach. The utility of the transatrial implantation technique is that it allows the use of state-of-the- art bipolar dual chamber pacemakers restoring access to all pacing modalities for those patients not candidates for transvenous implantation.
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Abstract
With the advent of tined transvenous cardiac pacing leads, the complete extraction of pacing leads in the treatment of an infected cardiac pacing system has become increasingly difficult. A method is described for the extraction of permanent pacing leads from the heart using alligator forceps inserted transvenously through the right internal jugular vein, grasping the lead near its insertion point in the cardiac muscle.
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Affiliation(s)
- J M Kratz
- Department of Surgery, Medical University of South Carolina, Charleston 29425
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Cope C, Larrieu AJ, Isaacson CS, Wolk LA, Ghosh SC, Rothkopf B. Transfemoral removal of a chronically implanted pacemaker lead: report of a case. Ann Thorac Surg 1986; 42:329-30. [PMID: 3753082 DOI: 10.1016/s0003-4975(10)62746-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A transfemoral angiographic technique was used to remove a chronically implanted, infected pacemaker wire that could not be withdrawn by using direct traction. The case and a description of the technique are detailed, and the principles of nonsurgical extraction of chronically implanted pacemaker wires are discussed.
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